Provider Demographics
NPI:1114090081
Name:FOTINOS, TIFFANY ANNE (NP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANNE
Last Name:FOTINOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 E. BELL ROAD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032
Mailing Address - Country:US
Mailing Address - Phone:480-443-8400
Mailing Address - Fax:480-443-8697
Practice Address - Street 1:4550 E. BELL ROAD
Practice Address - Street 2:SUITE 170
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032
Practice Address - Country:US
Practice Address - Phone:480-443-8400
Practice Address - Fax:480-443-8697
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2481363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP2481OtherLICENSE
AZ112598Medicare PIN